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What are the purposes of a health history?
To collect subjective and objective data. The history is combined with objective data from the physical examination and laboratory studies to form the database.
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What is subjective data?
Its what person says about himself or herself
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What is objective data?
Is what you observe through measurement, inspection, palpation, percussion and auscultation.
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What is the purpose of review of systems?
3 total: - to evaluate the past and present health state of each body system - To double check in case any significant data were omitted in the �present illness section� - to evaluate health promotion practices.
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What is sought after in the biographical data?
Name, address, DOB, age, sex, marital status, race, ethnic origin, occupation
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What is sought after in the source of history?
Record who is furnishing the information
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What is sought after in the reason for seeking care?
Brief spontaneous statement in the person�s own words that describes the reason for the visit
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What is sought after in the present health or history of present illness?
What is going on with them. Their general state of health. For the ill it�s a chronologic record of the reason for seeking care.
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When a person is telling you about any symptoms they are experiencing it should include eight critical characteristics. What are they?
Location, Character or Quality � burning, sharp, dull, aching; how intense, Quantity or severity � pain on a scale of 1-10, Timing � onset, duration, frequency, Setting � where or what was the person doing when the symptom started, aggravating or Relieving Factors � what makes the pain worse, Associated Factors � is the symptom associated with anything else, Patient�s perception � how has this symptom affected you
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What is sought after in the past history?
Past history is important because they may have residual effects on the current health state; accidents, hospitalizations, allergies, current meds
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What is sought after in the family history?
This will highlight those diseases and conditions for which a particular patient may be at increased risk
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An acronym for the 8 critical characteristics for present health
P � rovocative what brings it on, Q � uality how intense, R � egion where is the pain or issue, S - everity, T � ime onset, U � nderstand patient�s perception
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What is sought after in the review of functional assessment?
Measures the person�s self care ability; ADL � activities of daily living
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What is sought after in the perception of health?
How do they define health?
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What are some developmental considerations during a health history for an older adult?
Take your time since they might be hard of hearing, visual loss, loss of mobility
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What is a genogram?
A graphic family tree that uses symbols to depict the gender, relationship and age of immediate blood relatives in at least three generations.
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What do some of the symbols mean in a genogram or family tree?
A square represents a male, circle is female, a square with a diagonal line through it means a person died.
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What are the 4 physical exam techniques?
Inspection, palpation, percussion, and auscultation
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What is the reason you use inspection technique during assessment?
Purpose: general survey of the patient, concentrate on watching, When: 1st moment you meet the patient.How: use senses � sight, smell touch hearing, its always done 1st before any of the other techniques
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What is the reason you use palpation technique during assessment?
Purpose: touch � determine texture, size, consistency and location of body parts, When: Two types � light and deep. Light accustom patient to being touched. Deep � abdominal area, How: fingertips for fine tactile. Finger and thumb � position shape and consistency of an organ/mass. Dorsa of hand � to check temp.
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What is the reason you use percussion technique during assessment?
Purpose: Assess location size and density of underlying structures.When: since x-rays are not always readily available your hands always are, easy portable and give instant feedback, How: the art of striking one object against another to create sound
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What is the reason you use auscultation technique during assessment?
Purpose: listening to sounds produced by the body using a stethoscope � pitch, quality, loudness and duration, When: when you cant hear with your ear alone, How: using the stethoscope listen to the heart, blood vessels, lungs abdomen, blood pressure.
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Sounds of indirect percussion over normal lungs?
Resonant
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Sounds of indirect percussion over stomach intestine abdomen?
Tympany
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Sounds of indirect percussion over bone or tumor?
Flat
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Sounds of indirect percussion over organs?
Dull
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What are the four areas of a general survey?
Physical appearance, body structure, mobility, and behavior.
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What information is obtained during a general survey of physical appearance?
Age, gender, facial features
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What information is obtained during a general survey of body structure?
Nutrition, symmetry, obvious physical deformities.
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What information is obtained during a general survey of mobility?
Gait and range of motion
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What information is obtained during a general survey of behavior?
Facial expression, speech, dress, personal hygiene
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What are the various routes of temp measurement?
Oral, electronic thermometer, axillary, rectal, tympanic membrane thermometer
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What is the special consideration for checking temperature orally?
Quick, accurate and convenient
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What is the special consideration for checking temperature with an electronic thermometer?
Quick, accurate, unbreakable, disposable probe covers
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What is the special consideration for checking temperature axillary?
Safe and accurate, for infants young children
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What is the special consideration for checking temperature rectally?
Used when other routes are not practical ie. Cant close mouth
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What are the 4 qualities considered when assessing a pulse?
Rate normal for an adult 60-100, Rhythm normal is an even tempo, Force full normal weak and absent, Elasticity springy, straight
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Appropriate procedure for assessing normal respirations
Assess while person is unaware, count for 30 secs unless abnormally
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